Neuroimaging in Emergency Medicine: Ischemic Stroke, ICH (and SAH)

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Neuroimaging in Emergency MedicineIschemic
Stroke, ICH (and SAH)

• Peter D Schellinger, MD, PhD
• Department of Neurology
• University of Heidelberg
• Heidelberg, Germany

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Stroke

• Incidence 150-250 / 100.000
• Prevalence 800 / 100.000
• 3rd most common cause of death
• Leading cause of dependence
• Most expensive disease overall

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ICH is a common subtype of Stroke

• Increasing incidence
• 1030 of all strokes
• In the USA, 45,000 new cases of ICH/year
• Age gt55 years old
• Sex malesgtfemales
• Geographic variation
• Overall, 1020 per 100,000
• Afro-Americans and Japanese, 50 per 100,000

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Also ICH but not in this talk
SDH (Subdural Hemorrhage) EDH (Epidural
Hemorrhage) ICH (Intracerebral Hemorrhage)
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Two types of stroke -Same symptoms

• Occlusion
• Ischemic stroke
• (? 80)

Bleeding Intracerebral haemorrhage (?15)
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Two types of strokes -Diagnosed with imaging only

• Occlusion

Bleeding
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Two types of stroke -Different treatments

• Occlusion

Bleeding
Factor VII
Therapy Dissolve the clot Thrombolysis
Therapy Currently none - but
rt-PA
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Causes of SAH

• Aneurysm 70-75
• Angioma 10
• Arteriosclerosis 5-10
• Spinal Angioma 2-5
• Others 5

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SAHClinical presentation and Imaging

• Clinical presentation different from ICH and IS
• Only similar when either
• Secondary or concomitant ICH
• Subacute Vasospasm with stroke
• (CT-)Angiography
• Lumbar puncture
• Surgery vs intervention

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Ischemic Stroke
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Patients favorable outcome (modified Rankin 1)s
rt-PA Placebo p
3 mo 43 27 lt .001
6 mo 41 29 .001
12 mo 41 28 .001
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Global Outcome (mRS 0-1, Barthel Index 95-100,
NIHSS 0-1) Day 90 Adjusted Odds Ratio with 95
Confidence Interval N 2799
Metaanalysis NINDS, ECASS III, ATLANTIS
Adjustierte Odds Ratio
Time Interval (OTT) min
Lancet 2004, 363 768-774
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The hyperdense MCA sign

• 40-60 in angiographically proven occlusion
• 17 in unselected stroke patients

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The hyperdense MCA sign
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Sulcal Effacement

• Sulcal Effacement due to focal swelling
• Loss of grey/white differentiation

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Loss of the Insular Ribbon and Basal Ganglia
Hypoattenuation

• Obscuration of the right basal ganglia
  (arrowheads)
• Loss of demarcation of the insular cortex

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Early Infarct Signs and follow up
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Early Signs of a large infarction (gt 1/3 MCA sign)
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CT-Criteria ASPECTS
Normal 10 Pt
Cutoff 7 Pt
Complete MCA Infarction 0 Pt
Barber PA, Demchuk AM, Zhang J, Buchan AM.
Validity and reliability of a quantitative
computed tomography score in predicting outcome
of hyperacute stroke before thrombolytic therapy.
Aspects study group. Alberta stroke programme
early ct score. Lancet. 20003551670-1674.
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Early CT Signs Reading Tea Leaves
Sensitivity NINDS, ECASS I and II on site at
randomization 30-45
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NINDSAre Early CT signs relevant?

• Analysis of all baseline CTs 616/624 NINDS
  patients
• Incidence of Early CT Signs 31
• Significant Association Initial NIHSS Time
  Window
• No Association Outcome, Infarkt size, sICH Rate
• Conclusion Early CT signs do not influence the
  effect of rt-PA (within 3h time window !!!)
• Problem One-Third-MCA-territory criterion not
  tested

Patel et al, JAMA 2001
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Large or old infarction ??
3h?
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Hemorrhage or Ischemia ??
This is the question ??
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CT more or less normal or not ?
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CT more or less normal or not ?
Ø treat
Ø treat
Ø treat
Treat with rt-PA lt3h!!
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Intracerebral Hemorrhage
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Diagnosis

• There is no way to differentiate ICH from
  ischemic stroke by clinical means only
• Loss of consciousness ? DD posterior
  circulation
• Headache ? DD Migraine
• Vomiting ? DD Cerebellar Stroke

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Primary ICH - etiology
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Primary ICH (gt80)

• Hypertension (RRR of 50 when treated)
• Amyloid (kongophilic) Angiopathy
• Microaneurysms, Leucoaraiosis
• Alcohol abuse
• No obvious underlying pathology

Correct Imaging Based Classification by Experts
in only 66.8
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Diagnostic Standard for ICH CT
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Subtypes by localization
A
C
Lobar 3452
D
E
B
Deep 3048
Infratentorial, Cerebellar 915
Qureshi et al. N Engl J Med 2001
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Imaging signs of poor prognosis
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Differential Diagnosis
Primary Lymphoma
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ComplicationsEarly increase in ICH volume
CT control Brott 1997 n 103 Prosp. () Fujii 1994 n 419 Retrosp. () Flibotte 2004 n 35 Retrosp. () Kazui 1996 n 204 Retrosp. ()
03 h 26 18 54 36
36 h NA 8 NA 16
06 h NA 17 NA 52
324 h 12 2 NA 10
Increase in ICH volume and re-bleeding is
associated with clinical deterioration
Warfarin
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Sequential CT StudiesEarly Growth / Rebleeding

• This CCT confirms the most likely cause of early
  clinical deterioration in patients with acute
  ICH
• Re-bleeding
• Intraventricular blood (IVH)

95 min after SO
3 h after SO
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Elevated ICP Glioblastoma multiforme
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Elevated ICPICH Maximum Damage
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ComplicationsCSF Circulation Blockade
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External Ventricular Drainage (EVD)
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Effects / Complications of ICH

• Primary
• Growth
• ICP elevation
• Secondary
• Oedema
• Intraventricular extension
• Hydrocephalus
• Seizure